Form SFMO-1 "Application for the Use of Pyrotechnics Inside State-Owned Buildings and Outdoors on State-Owned Property Before a Proximate Audience" - Virginia

What Is Form SFMO-1?

This is a legal form that was released by the Virginia Department of Fire Programs - a government authority operating within Virginia. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 7, 2015;
  • The latest edition provided by the Virginia Department of Fire Programs;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form SFMO-1 by clicking the link below or browse more documents and templates provided by the Virginia Department of Fire Programs.

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Download Form SFMO-1 "Application for the Use of Pyrotechnics Inside State-Owned Buildings and Outdoors on State-Owned Property Before a Proximate Audience" - Virginia

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Read and comply with application instructions that begin on page 5.
Virginia State Fire Marshal’s Office
Application for the USE of PYROTECHNICS
1126
INSIDE State-owned Buildings and
OUTDOORS on State-owned Property Before
a Proximate Audience
1. Applicant Name/Company:
2. Applicant Phone #:
3. Applicant Mailing address:
3b. Applicant Email address:
Applicant FAX #:
4. Applicant Physical address if different from Line 3:
5. City/State/Zip:
6. Applicant F.I.D. (Federal Identification
Number):
7. “Designated individual”:
See instructions for more information on “Designated individual”.
(Print name, Last, First, MI)
Card number:
(Photo copy of card is to be
attached to this application.)
8. Of the following, check all that may apply and for which application is being made:
8.1. [ ] For the use of pyrotechnics in theatrical, musical or
8.5. [ ] The outdoor use of pyrotechnics at distances less
similar productions before a proximate audience,
than those required by NFPA 1123, Code for Fireworks
performers, or support personnel.
Display, as referenced by Section 5608.2.2 of the
Virginia Statewide Fire Prevention Code.
8.2. [ ] The use of pyrotechnics while videotaping, audio
taping, or filming of any television, radio, or movie
production where such production takes place before a
Note: This application and any permit issued as a result do
proximate audience.
not confer approval to use flammable liquids and/or
8.3. [ ] The rehearsal of any production in which
flammable gases in any performance or display. A
pyrotechnics are used.
separate application and permit is required for the use of
8.4. [ ] The indoor use of pyrotechnics.
flame effects before a proximate audience.
9.
Sponsorship.
9.1. The use of pyrotechnic materials and/or devices will be sponsored by:
9.2. The use of pyrotechnics will occur at (Provide location by listing address, name of complex or facility, name or
building number, etc. Include name of City, County or Town):
9.2.1. Name of venue manager: ________________________________________________________
9.3. The use of pyrotechnic materials and/or devices at the location listed above will occur (check one):
st
9.3.1. [ ] Inside a state-owned building
($350.00 permit fee for 1
day plus $150/day for any succeeding days.)
st
9.3.2. [ ] Outside on state-owned property
($250.00 permit fee for 1
day plus $150/day for any succeeding days.)
10. The use of pyrotechnic materials and/or devices will occur on:
(Date): _______ / ______ / 20 ____ beginning at (time) ______:____ am/pm and end at (time) ______:____ am/pm.
SFMO- 1 Revised: July 14, 2014 December 7, 2015
1126 Application
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Read and comply with application instructions that begin on page 5.
Virginia State Fire Marshal’s Office
Application for the USE of PYROTECHNICS
1126
INSIDE State-owned Buildings and
OUTDOORS on State-owned Property Before
a Proximate Audience
1. Applicant Name/Company:
2. Applicant Phone #:
3. Applicant Mailing address:
3b. Applicant Email address:
Applicant FAX #:
4. Applicant Physical address if different from Line 3:
5. City/State/Zip:
6. Applicant F.I.D. (Federal Identification
Number):
7. “Designated individual”:
See instructions for more information on “Designated individual”.
(Print name, Last, First, MI)
Card number:
(Photo copy of card is to be
attached to this application.)
8. Of the following, check all that may apply and for which application is being made:
8.1. [ ] For the use of pyrotechnics in theatrical, musical or
8.5. [ ] The outdoor use of pyrotechnics at distances less
similar productions before a proximate audience,
than those required by NFPA 1123, Code for Fireworks
performers, or support personnel.
Display, as referenced by Section 5608.2.2 of the
Virginia Statewide Fire Prevention Code.
8.2. [ ] The use of pyrotechnics while videotaping, audio
taping, or filming of any television, radio, or movie
production where such production takes place before a
Note: This application and any permit issued as a result do
proximate audience.
not confer approval to use flammable liquids and/or
8.3. [ ] The rehearsal of any production in which
flammable gases in any performance or display. A
pyrotechnics are used.
separate application and permit is required for the use of
8.4. [ ] The indoor use of pyrotechnics.
flame effects before a proximate audience.
9.
Sponsorship.
9.1. The use of pyrotechnic materials and/or devices will be sponsored by:
9.2. The use of pyrotechnics will occur at (Provide location by listing address, name of complex or facility, name or
building number, etc. Include name of City, County or Town):
9.2.1. Name of venue manager: ________________________________________________________
9.3. The use of pyrotechnic materials and/or devices at the location listed above will occur (check one):
st
9.3.1. [ ] Inside a state-owned building
($350.00 permit fee for 1
day plus $150/day for any succeeding days.)
st
9.3.2. [ ] Outside on state-owned property
($250.00 permit fee for 1
day plus $150/day for any succeeding days.)
10. The use of pyrotechnic materials and/or devices will occur on:
(Date): _______ / ______ / 20 ____ beginning at (time) ______:____ am/pm and end at (time) ______:____ am/pm.
SFMO- 1 Revised: July 14, 2014 December 7, 2015
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Read and comply with application instructions that begin on page 5.
10.1. [ ] Check this box if the firing of identical pyrotechnic materials or device setups will occur on multiple
consecutive days (sequential dates). List all the dates and times on a separate page and attach it to this application.
(For important permit fee information, see application instructions for Line 9.3.)
11. A walk-through and representative demonstration of the pyrotechnics should be conducted and would be available
to commence on (date) ____ / ____ / 20___ at (time) _____ : _____ AM / PM prior to the first rehearsal, production
and/or performance at which the pyrotechnics will be used. The demonstration will be completed and followed with
sufficient time afterward to reset/reload the pyrotechnics before the arrival of any audience. IMPORTANT: If Line 10.1 is
checked for multi-day setups that are identical in location, types and number of devices, the demonstration need be
conducted only once. ►If the demonstration is not ready or is not performed in a timely manner, the applicant and venue
manager risk a delay or denial for the use of pyrotechnics because sufficient time was not provided prior to audience
arrival and would not be a qualifying reason for a refund of the permit fee.
12. Operators, Assistants and Pyrotechnic Specifications.
12.1. Provide the name and the Virginia certification number of the Pyrotechnician that will be in charge of firing
the pyrotechnics. Attach a copy of that person’s certification card.
Name (Print – last, First, MI)
Certification #
12.2. Name and ages of all assistants who will be present (attach additional pages as needed):
Name (Print – Last, First, MI)
(See application instructions.)
Age
12.3. List the number and types of pyrotechnic devices or materials to be used (attach additional pages as
needed):
(See application instructions.)
#
Name of device or material
DOT class
13. Additional Attachments.
The following items are to be provided as attachments to this application.
13.1. [ ] A diagram of the grounds or facilities where the production is to be held. (See application
instructions.) The diagram is to show:
13.1.1. [ ] the point at which the pyrotechnic devices are to be positioned and fired,
13.1.2. [ ] the fallout radius for each pyrotechnic device used in the performance,
13.1.3. [ ] the lines behind which the audience will be restrained, and
13.1.4. [ ] The point of on-site assembly of pyrotechnic devices.
SFMO- 1 Revised: July 14, 2014 December 7, 2015
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Read and comply with application instructions that begin on page 5.
13.2. [ ] A material safety data sheet (MSDS) for the pyrotechnic material(s) to be used including:
13.2.1. [ ] the name, address and phone number of the manufacturer, and
13.2.2. [ ] whether it is to be used with any special considerations or cautions.
(See NFPA 1126-11, Section 7.1, [4] and [5].)
13.4. [ ] Certification that the set, scenery, and rigging materials are inherently flame-retardant or have
been treated to achieve flame retardancy.
[ ] Check this box if this item is not applicable to
the circumstance.
13.5. [ ] Proof of a corporate surety bond or a public liability insurance policy in an amount acceptable to
the sponsor noted on Line 9.1 and/or venue manage listed on Line 9.2.1 but not less than
$1,000,000.00.
Special Instructions
Submit one (1) copy of this application complete with all attachments to the SFMO. The SFMO
must be in receipt of this application at the address listed below not less than 15 days prior to the
event to avoid a higher required fee. A post mark or its equivalent is not the determining factor for
having submitted an application in a timely manner. See the fee increase schedule in Section
107.11 of the Statewide Fire Prevention Code for information on applications received less than 15
days prior to the event.
If an application is received with incomplete information or incorrect fee, the application may be
returned without further processing resulting in the potential of a higher fee based upon SFMO
receipt of a complete application and the fee schedule as found in SFPC Section 107.11.
After initial review, a provisional permit will be issued. After a completed and satisfactory site
inspection at the location and date indicated on Lines 9.2 and 10 respectively, the SFMO
representative in attendance will convert the provisional permit to a finalized permit.
14. By my signature below, I attest the information provided is complete and accurate. I acknowledge and agree to
comply with all applicable requirements of the Virginia Statewide Fire Prevention Code (SFPC) and the referenced NFPA
1126-11 standard governing the use, storage and firing of pyrotechnics, even those not specifically covered or expressed
on this application.
I also acknowledge that if a permit is issued it shall be valid only at the location listed on the application and for the
specific date(s) and time(s) for which it is issued.
If approved to proceed, I acknowledge that such approval is conditional upon continued compliance with the SFPC. I
further acknowledge and understand that any SFPC violations identified after approval to proceed may result in denial of
final permit issuance or immediate suspension or revocation of a permit.
In the form of a check or money order made payable to the TREASURER OF VIRGINIA, this application and
attachments are submitted with the required and non-refundable permit fee as noted on Line 9.3 and the application
instructions for Line 9.3.
Signature of “designated individual” (person listed on line 7):
Date:
15.
IMPORTANT:
This application has 4 pages plus all the pages of your attachment(s). Be
sure to complete the next page (page 4) of this application.
(The 3 pages of
application instructions do not need to be mailed to the SFMO.)
The application and attachments are to be delivered to:
State Fire Marshal’s Office
Virginia Department of Fire Programs
1005 Technology Park Drive
Glen Allen, Virginia 23059-4500
SFMO- 1 Revised: July 14, 2014 December 7, 2015
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Read and comply with application instructions that begin on page 5.
Permit for a Fireworks Display on
State-owned Property
1126
(Invalid if not completed by SFMO.)
Upon SFMO signature(s), a copy of this page will be returned to
the applicant as a permit.
Applicant:
The following information fields may be repeated from earlier pages and are to be completed by the applicant.
Applicant Name/Company:
Applicant Phone #:
Applicant eMail address:
Applicant FAX #:
Signature of Applicant’s “Designated individual”:
See instructions for more information on “Designated individual”.
Card number:
Display location:
The use of pyrotechnic materials will occur at (Provide location by listing address, street intersections, name of complex
or facility, etc. Include name of City, County or Town):
Display Date:
The use of pyrotechnic materials firing of display fireworks will occur on:
(Date): _______ / ______ / 20 ____ beginning at (time) ______:____ am/pm and end at (time) ______:____ am/pm.
[ ]
Check this box if the firing of identical display firework setups will occur on consecutive (sequential) dates and/or times.
Provisional Permit
to be completed by SFMO personnel only:
Preliminary application review by (print name):
SFMO representative’s signature:
Preliminary review date:
Based on Applicant’s submittal for permit, a provisional permit is recommended with the following added conditions, corrections or adjustments:
Finalized Permit
to be completed by SFMO personnel only.
Final review date:
SFMO representative’s
SFMO final review and
inspection by (print name):
signature:
A finalized permit is granted with the following added conditions, corrections or adjustments:
Transportation vehicle information
(If multiple vehicles used, add additional page.)
Vehicle license (tag number)
Vehicle tag state of
DOT number (if applicable)
issuance
Vehicle driven by (print name)
Driver’s license number
Driver’s license state
of issuance
SFMO- 1 Revised: July 14, 2014 December 7, 2015
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Read and comply with application instructions that begin on page 5.
State Fire Marshal’s Office
Virginia Department of Fire Programs
Application for the USE OF PYROTECHNICS INSIDE State-owned
buildings and OUTDOORS on State-owned Property Before a Proximate
Audience
1126
Instructions
All information must be printed in ink or typewritten.
Submit only one (1) copy of this application and all its attachments to the SFMO. The
SFMO must be in receipt of a complete application not less than 15 days prior to the
event to avoid an increase in the required fee. A post mark or its equivalent is not
the determining factor for having submitted an application in a timely manner. See
the fee increase schedule in Statewide Fire Prevention Code Section 107.11 for
information on applications received less than 15 days prior to the planned event.
Line 1. Provide name of person or company applying for a permit.
Line 2. List telephone number where applicant may be reached.
Line 3 & 3b. Use mailing address the applicant can expect the quickest service. If available, provide email address
and/or fax number.
Line 4. What is the physical address (location) of the permit applicant if it’s different from the mailing address given?
Line 5. List city, state and zip code for the complete mailing address.
Line 6. Provide the firework vendor’s Federal Identification Number as provided by the IRS.
Line 7. A “designated individual” is defined as “a person in possession of a Background Clearance Card (BCC) issued by the
SFMO, or is certified by the SFMO as a Pyrotechnician, …(either of) whom are responsible for (i) ensuring compliance with state
law and regulations relating to blasting agents and explosives, (ii) applying for explosives or firework permits, (iii) is at least 21 years
of age, and (iv) shall demonstrate the capability to effectively communicate safety messages verbally and in writing in the English
language.”
The “Designated individual” is to print their name and card number in the spaces provided. In accordance with
SFPC Section 5601.2.3.1, the SFMO shall deny the application for permit if the application does not contain a designated
individual’s name and signature as representing the applicant. Space is provided on Line 14 for the designated
individual’s signature. Attach a photo-copy of the designated individual’s card to the application. (The Pyrotechnician
named on Line 12.1 may also be the designated individual and/or applicant which results in repeated listings.)
Line 8. The use of pyrotechnics before a “proximate audience” is governed by provisions contained in the Virginia
Statewide Fire Prevention Code (SFPC) and its incorporated NFPA 1126-11 standard.
This application is for a permit
to use NFPA 1126 – type devices,
“close proximity
fireworks”, in circumstances listed on
sometimes referred to as
lines 8.1 through 8.5.
(If the applicant desires to use pyrotechnics or materials in circumstances not listed, the applicant should
immediately consult with the State Fire Marshal’s Office for further guidance, direction or information.)
Line 9. The SFPC requires a “plan for the use of pyrotechnics”. The specifics of the plan are paraphrased and spread
throughout the application.
Line 9.1. The plan is to include the name of the sponsoring group, person or organization.
SFMO- 1 Revised: July 14, 2014 December 7, 2015
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